HESI practice
Which secondary skin lesion may include athlete's foot as an example? Scar Scale Ulcer Fissure
Fissure An example of a fissure-type secondary lesion is athlete's foot. Surgical incisions and healed wounds are examples of scar-type secondary lesions. A scale-type secondary lesion would include flaking of the skin after a medication reaction or sunburn. Ulcer-type lesions may include pressure ulcers or chancres.
Which is a characteristic of the glands that secrete a thick substance in response to emotional stimulation and become odoriferous because of bacterial action? Highly active in childhood Absent around the umbilicus Widely distributed throughout the body Grow in conjunction with axillary hair follicles
Grow in conjunction with axillary hair follicles The apocrine sweat glands secrete a thick substance in response to emotional stimulation and become odoriferous because of bacterial action. These glands grow in conjunction with hair follicles around the axillae. The apocrine glands are inactive during childhood and reach their secretory potential at the time of puberty. The apocrine glands are situated around the umbilicus. They have limited distribution and are found only around the axillae, areolae, external auditory canal, and anal and genital regions. Eccrine sweat glands, not the apocrine glands, have wide distribution throughout the body.
The nurse would assess for which electrolyte imbalance during the first 48 hours after a client has sustained a thermal injury? Hypokalemia and hyponatremia Hyperkalemia and hyponatremia Hypokalemia and hypernatremia Hyperkalemia and hypernatremia
Hyperkalemia and hyponatremia Massive amounts of potassium are released from the injured cells into the extracellular fluid compartment; large amounts of sodium are lost in edema. Serum potassium will rise, leading to hyperkalemia. Serum sodium deficit will occur, leading to hyponatremia.
According to the Erikson's theory, which stage in a young adult describes the development of the sense of caring for others? Initiative versus guilt Integrity versus despair Intimacy versus isolation Identity versus role confusion
Intimacy versus isolation The development of a sense of caring for others in a young adult occurs at the stage of intimacy versus isolation. During the initiative versus guilt stage, a child likes to pretend and try out new roles. At the integrity versus despair stage, many older adults view their lives with a sense of satisfaction. During the identity versus role confusion stage, a child's identity development begins with the goal of achieving some perspective or direction.
Which description would the nurse provide the parents of an infant who are asking about what a patent ductus arteriosus (PDA) is? The diameter of the aorta is enlarged. The wall between the right and left ventricles is open. It is a narrowing of the entrance to the pulmonary artery. It is a connection between the pulmonary artery and the aorta
It is a connection between the pulmonary artery and the aorta Before birth, oxygenated fetal blood is shunted directly into the systemic circulation by way of the ductus arteriosus, a connection between the pulmonary artery and the aorta. After birth, the increased oxygen tension causes a functional closure of the ductus arteriosus. Occasionally, particularly in preterm infants, this vessel remains open, a condition known as patent ductus arteriosus. Enlargement of the diameter of the aorta is not the problem in patent ductus arteriosus. A defective wall between the right and left ventricles is a description of ventricular septal defect. A narrowing of the entrance to the pulmonary artery is a description of pulmonic stenosis.
The nurse is caring for an adolescent admitted to the hospital after taking an acetaminophen overdose. Which result is most important for the nurse to monitor at this time? Blood gas level Liver function tests Complete blood count Glycosylated hemoglobin
Liver function tests Acetaminophen is metabolized by the liver, and an excess may result in increased aspartate aminotransferase and bilirubin levels and prothrombin time. Hepatic involvement may last as long as 7 days, and liver damage may be permanent. Blood gas results are not the priority at this time. They will become important if hepatic failure or respiratory distress develops. The hematologic components measured in a complete blood count are not profoundly affected by an acetaminophen overdose. Glycosylated hemoglobin is a measure of diabetic control, not a measure of response to an acetaminophen overdose.
A pregnant client's blood test reveals an increased alpha-fetoprotein (AFP) level. Which condition is indicated with this result? Cystic fibrosis Phenylketonuria Down syndrome Neural tube defect
Neural tube defect Increased levels of alpha-fetoprotein in pregnant women have been found to reflect open neural tube defects such as spina bifida and anencephaly. Cystic fibrosis is a genetic defect that is not associated with the AFP level. A Guthrie test soon after ingestion of formula can determine whether an infant has phenylketonuria. Down syndrome is a chromosomal defect that is associated with a low AFP level.
The nurse in the clinic is obtaining the health history of a 16-year-old boy with a complaint of a thick urethral discharge. Which is the most appropriate nursing action to help confirm a tentative diagnosis of gonorrhea? Assessing the temperature for fever Collecting a urine sample for a urinalysis Drawing blood for a complete blood count Obtaining a urethral specimen for a culture
Obtaining a urethral specimen for a culture When the Gonococcus organism is present in the genitourinary tract of a male client, a culture of the urethral exudate provides a definitive diagnosis. Fever is not a specific diagnostic tool, because it occurs with other infections. Although urine may contain Gonococcus organisms, the urine dilutes the concentration; the organisms are more concentrated in the urethral discharge. The Gonococcus organism is in the genitourinary tract, not the blood; a complete blood count will not provide information with which to diagnose gonorrhea.
Which part of the female reproductive system produces testosterone? Uterus Ovary Fallopian tube Ovarian follicle
Ovary Testosterone is an androgen, and in females, androgens are produced by the ovaries and adrenal glands. The uterus holds the fetus during pregnancy. Fallopian tubes facilitate fertilization of oocyte and sperm. An ovarian follicle is a collection of oocytes in the ovary.
What is the inflammation of the skin at the base of the nail called? Paronychia Koilonychia Beau lines Splinter hemorrhage
Paronychia Paronychia is the inflammation of skin at the base of nail. Concavely curved nails are called koilonychias. Transverse depressions in nails indicating a temporary disturbance of nail growth are called Beau lines. Red or brown linear streaks in the nail bed are caused by minor trauma to nails, subacute endocarditis, or trichinosis and are called splinter hemorrhages.
A 15-year-old with cystic fibrosis (CF) is admitted with a respiratory infection. The nurse determines that the adolescent is cyanotic, has a barrel-shaped chest, and is in the 10th percentile for both height and weight. Which is the priority nursing intervention? Increasing physical activities Performing postural drainage Maintaining dietary restrictions Administering prescribed pancreatic enzymes
Performing postural drainage Postural drainage, including percussion and vibration, aids in removal of respiratory secretions that provide a medium for further bacterial growth. Children with CF must cope with impaired gas exchange that results in intolerance to activity. Increasing activity at this time may be too taxing. There must be a balance between activity and rest within the child's limitations. There are no dietary restrictions. Children with CF should have a balanced nutritional intake that is high in calories. Although important, administration of prescribed pancreatic enzymes is not the priority.
Which symptoms would be concerning for fluid volume excess in a child with a diagnosis of acute poststreptococcal glomerulonephritis? Dysuria, rash, pruritus Diarrhea, polyuria, weight loss Hypotension, tachycardia, proteinuria Periorbital edema, smoky urine, headaches
Periorbital edema, smoky urine, headaches Periorbital edema indicates fluid retention, and headaches are a symptom of hypertension. Glomeruli are edematous and infiltrated with white blood cells that occlude the capillary lumen; hematuria results from kidney damage. Skin disorders and dysuria are not related to fluid overload. Diarrhea, polyuria, and weight loss are not related to fluid volume excess. Nor are hypotension and proteinuria related to a fluid volume excess; however, cardiac problems are complications that occur if the fluid overload is not corrected or becomes severe.
Which assessment finding is a late sign of heart failure? Tachypnea Tachycardia Peripheral edema Periorbital edema
Peripheral edema Heart failure is characterized by a decrease in blood flow to the kidneys, causing sodium and water reabsorption and resulting in peripheral edema. The peripheral edema indicates severe cardiac decompensation. Tachypnea and tachycardia constitute an early attempt by the body to compensate for decreased cardiac output. Periorbital edema occurs most noticeably in children with acute poststreptococcal glomerulonephritis, not heart failure.
Which physiological response occurs first when a client experiences sudden hypovolemia caused by hemorrhage? Peripheral vasoconstriction Elevation of serum cortisol level Release of immature erythrocytes Increased antidiuretic hormone (ADH)
Peripheral vasoconstriction The initial response to hemorrhage is activation of the sympathetic nervous system, leading to increases in heart rate and peripheral vasoconstriction, which shunts blood to essential core organs. The other responses also occur, but more slowly. Cortisol increases as part of the stress response, leading to fluid retention, but this process occurs more slowly. Immature red blood cells (erythrocytes) are released from the bone marrow, but this occurs more slowly than vasoconstriction. An increase in ADH causes fluid retention, but this occurs more slowly.
Which key feature is associated with a stage 2 pressure ulcer? Presence of nonintact skin Development of sinus tracts Damage to the subcutaneous tissues Appearance of a reddened area over a bony prominence
Presence of nonintact skin The skin is nonintact in stage 2 of pressure ulcers. Sinus tracts may develop during stage 4 of pressure ulcers. The subcutaneous tissue becomes damaged or necrotic during stage 3 of pressure ulcers. A reddened area over a bony surface occurs in stage 1 of pressure ulcers.
Which benign condition shows silver scaly plaques on the skin? Nevi Psoriasis Urticaria Acne vulgaris
Psoriasis A silver, scaly plaque on the skin is due to psoriasis and is most commonly seen on the elbows and scalp. Hyperpigmented areas that vary in form and color are due to nevi. Spontaneously occurring raised or irregular-shaped wheals of varying size are usually due to urticaria. Noninflammatory lesions, including open comedones and closed comedones, are due to acne vulgaris.
Electrocardiography (ECG) is scheduled for an infant who has tetralogy of Fallot. The mother asks the nurse what type of test this is and why it is done. Which is the best response by the nurse? "It's a type of x-ray that shows us the size of the baby's heart." "Electrical activity in the baby's heart is recorded, then printed on graph paper." "It's an ultrasound procedure that produces images of the structures in the baby's heart." "Contrast material is injected into the baby's vein to visualize the flow of blood through the heart."
"Electrical activity in the baby's heart is recorded, then printed on graph paper." An ECG not only records electrical impulses in the heart but can also reveal atrial and ventricular hypertrophy. The x-ray procedure that shows the size of a baby's heart is a chest x-ray. The ultrasound procedure that would be used to produce images of the structures in a baby's heart is the echocardiogram. The intravenous injection of contrast material to visualize the flow of blood through the heart is an angiogram.
Which of these thoughts in an adolescent corresponds to a sense of "invulnerability"? "My doll will cry if I will ignore her for too long." "If my football gets deflated, I can reinflate it." "I need to look beautiful because everyone has their eyes on me." "Even if i drive my car at 120 miles per hour, nothing will happen to me."
"Even if i drive my car at 120 miles per hour, nothing will happen to me." An adolescent who thinks that risky driving does not pose a threat demonstrates a sense of "invulnerability." A preschooler concerned about his or her doll demonstrates animism. When a teen believes that everyone is paying attention to him or her, this thought denotes the feeling of personal fable. When an individual thinks that a deflated football can be inflated again, this thought shows the concept of reversibility.
Which client has an increased risk of developing IgE antibodies? A client with pollen allergy A client undergoing a poison ivy reaction A client with bacterial infection A client undergoing a blood transfusion
A client with pollen allergy A client with a pollen allergy develops IgE antibodies that may result in an anaphylactic reaction. A client with poison ivy develops delayed hypersensitivity, which is mediated by T lymphocytes. A client with a bacterial infection develops IgG and IgM antibodies. A client undergoing blood transfusion may develop IgG and IgM type II hypersensitivity reactions.
Which gastrointestinal (GI) change may be found in the client with burn injuries? Abdominal distention Increased peristalsis Activation of GI motility Increased blood flow to the GI area
Abdominal distention The client with burn injuries may have abdominal distention due to loss of peristalsis. Gastrointestinal motility may be inhibited with burn injuries. Blood flow may be reduced and mucosal damage might have occurred.
A newborn with Erb palsy has an asymmetric Moro reflex. Which cause would the nurse suspect? Acquired in utero A tumor arising from muscle tissue An X-linked inheritance pattern An injury to the shoulder during birth
An injury to the shoulder during birth Erb palsy results from forces that alter the alignment of the arm, shoulder, and neck; stretching or pulling away of the shoulder from the head during birth damages the brachial plexus. Erb palsy is not acquired in utero and is not a tumor or an X-linked inherited disease.
The nurse assesses a client and determines that she has achieved thelarche. Which clinical finding prompted the nurse's report? Appearance of breast buds Occurrence of gynecomastia Growth of hair on mons pubis Occurrence of menstrual cycle
Appearance of breast buds The appearance of breast buds is considered to be an initial indication of puberty and is known as thelarche. A few months after thelarche, growth of pubic hair on the mons pubis occurs. This is known as adrenarche. The occurrence of the first menstrual cycle is known as menarche. Temporary gynecomastia is seen in some boys during mid-puberty.
Which information would the nurse include when explaining the cause of transient ischemic attacks (TIAs) to a client? Genetic valvular heart disease Atherosclerotic plaques within arteries Developmental defects in arterial walls Emboli ascending from the lower extremities
Atherosclerotic plaques within arteries Atherosclerotic plaques within arteries progressively narrow the lumens of the carotid arteries, causing TIAs. Valvular defects usually cause cerebral emboli that result in a brain attack. Brain aneurysms are developmental defects that may rupture, resulting in a brain attack. Emboli arising from the lower extremities usually result in occlusions in the pulmonary vascular system, causing a pulmonary embolus.
The nurse receives an order to prepare a solution for administering a cleansing enema for an adolescent client. Which is the volume of solution that would be prepared? 150 to 250 mL 250 to 350 mL 300 to 500 mL 500 to 750 mL
500 to 750 mL In adolescents, the volume of solution required is 500 to 750 mL. The nurse would prepare 150 to 250 mL of warmed solution for infants. The nurse would prepare 250 to 350 mL of warmed solution for administering a cleansing enema in a toddler. In school-age children, the volume of warmed solution is 300 to 500 mL.
A 20-lb infant has a normal saline enema ordered, at a dose of 10 mL/kg. Which dose would the nurse administer? 9 mL 90 mL 130 mL 210 mL
90 mL First, the nurse must convert to kg by dividing 20/2.2 = 9.09 kg. 9.09 × 10 mL/kg = 90 mL dose to be administered.
An adolescent who has just been found to have type 1 diabetes asks the nurse about exercise. Which is the best response by the nurse? "Exercise should be restricted." "Exercise will increase blood glucose." "Extra snacks are needed before exercise." "Extra insulin is required during exercise.
"Extra snacks are needed before exercise." Exercise lowers the blood glucose level; an extra snack can prevent hypoglycemia. Exercise is encouraged, not restricted. Exercise lowers, not increases, blood glucose. Extra insulin is contraindicated because exercise decreases the blood glucose level; extra insulin may precipitate hypoglycemia.
After the nurse has finished teaching a client about sickle cell anemia, which statement indicates that the client has a correct understanding of the condition? "I have abnormal platelets." "I have abnormal hemoglobin." "I have abnormal hematocrit." "I have abnormal white blood cells."
"I have abnormal hemoglobin." The patient with sickle cell anemia has abnormal hemoglobin, hemoglobin S, causing the red blood cells to stiffen and elongate into a sickle. Although it can affect hematocrit, it is really a result of the abnormal hemoglobin. The disorder affects hemoglobin rather than platelets or white blood cells.
A teenager is being discharged with a cast. Which would the nurse recommend if the client experiences pruritus around the cast edges? "Scratch the itchy area gently." "Put an ice pack on the affected area." "Sprinkle a layer of powder around the itchy spots." "Ask your doctor for a prescription for an antihistamine."
"Put an ice pack on the affected area." An ice pack numbs the area and may temporarily diminish the discomfort. Scratching stimulates the release of histamine, which worsens the pruritus; also, scratching may break the skin and open an avenue for infection. Powder may become caked and slip under the cast, causing additional discomfort. Also, powder should be avoided because it is toxic if inhaled. Antihistamines are not prescribed unless all other measures have failed.
Which functions does the nurse associate with the epidermis? Select all that apply. One, some, or all responses may be correct. Serves as an energy reserve Provides cells for wound healing Serves as a mechanical shock absorber Inhibits proliferation of microorganisms Allows the photoconversion of 7-dehydrocholesterol to vitamin D
-Inhibits proliferation of microorganisms -Allows the photoconversion of 7-dehydrocholesterol to vitamin D The epidermis inhibits the proliferation of microorganisms because of its dry external surface. It also allows for the photoconversion of 7-dehydrocholesterol to vitamin D. The subcutaneous tissue serves as an energy reserve. The dermis helps in providing cells for wound healing. Subcutaneous tissue acts as a mechanical shock absorber.
How would the nurse determine the length of tube needed to reach the stomach for nasogastric feeding? The tube is advanced until resistance is met. The tube is advanced until gastric contents are aspirated. A measurement is made from nose to earlobe and then to the epigastric area. A measurement is made from mouth to umbilicus and then half that distance is added.
A measurement is made from nose to earlobe and then to the epigastric area. Before inserting the gastric tube, the nurse measures the anatomic pathway that the tube will travel, which is from the nose to the earlobe (corresponding to the nasopharynx) to the epigastric area of the abdomen (the lower end of the stomach). The tube is then marked and inserted until the mark is reached. Advancing the tube without measuring for the potential length of the tube to reach the stomach is unsafe. Without premeasuring, the tube may be advanced too far or not far enough. Inserting the tube to the point where gastric contents are aspirated may not place the tube well into the stomach, which can increase the risk of aspiration. Measuring from mouth to umbilicus and then adding half that distance will yield a distance that is too long.
The nurse described a client's abnormal breath sounds and included crackles, rhonchi, wheezes, and pleural friction rubs. Which breath sounds did the nurse hear? Vesicular Bronchial Adventitious Bronchovesicular
Adventitious Adventitious sounds are described as abnormal extra breath sounds to include crackles, rhonchi, wheezes, and pleural friction rubs. Vesicular sounds are relatively soft, low-pitched, gentle, rustling sounds. Bronchial sounds are louder and higher pitched and resemble air blowing through a hollow pipe. Bronchovesicular sounds have a medium pitch and intensity and are heard over the mainstem bronchi on either side of the sternum and posteriorly between the scapulae.
Which organism is responsible for causing Lyme disease in clients? Phthirus pubis Sarcoptes scabiei Borrelia burgdorferi Pediculus humanus var. corporis
Borrelia burgdorferi Lyme disease is a bacterial infection caused by Borrelia burgdorferi, which is transmitted by ticks. Phthirus pubis causes pediculosis. Scabies is caused by Sarcoptes scabiei. Pediculus humanus var. corporis also causes pediculosis.
To which part of the respiratory system would the client's radiology report refer when identifying the angle of Louis? Hilum Carina Alveoli Epiglottis
Carina Located at the level of the manubriosternal junction, the carina is also referred to as the angle of Louis. The mainstream bronchi, pulmonary vessels, and nerves enter the lungs through a slit called the hilum. Alveoli are small sacs that are the primary site of gas exchange in the lungs. The epiglottis is a small flap located behind the tongue that closes over the larynx during swallowing.
Which comorbidity is associated Down syndrome? Renal disease Hepatic defects Congenital heart disease Endocrine gland malfunction
Congenital heart disease Many children with Down syndrome have cardiac anomalies, most often ventricular septal defects, which can be life threatening. Renal disease, hepatic defects, and endocrine gland malfunction are not characteristic findings in children with Down syndrome.
Which statement should be considered when teaching measures to prevent lead poisoning in children? Lead poisoning is known to be caused by the ingestion of foods that are high in fat. Lead poisoning is attributed to an indigent and passive parent who fails to supervise the children. Environmental factors are involved because lead is available for ingestion and inhalation. Increasing milk intake will counteract the adverse effects of lead ingestion.
Environmental factors are involved because lead is available for ingestion and inhalation. Lead poisoning is caused by lead in the environment. Sources of lead may include deteriorating paint in a home (inhaled or ingested); lead in products that are used daily, such as batteries, pottery, and glass (ingested); and lead in the atmosphere (which may be inhaled or fall on food that is then ingested). Unless the fat has been exposed to lead, it is not a causative factor. The role of parents is not an identified factor. Socioeconomic status is just one causative factor; there are many others. Milk does not counteract the effects of lead. Also, the teaching regards causes of lead poisoning, not treatments.
Which part of the upper respiratory system is involved in equalizing the pressure within the middle ear while swallowing? Glottis Paranasal sinus Palatine tonsils Eustachian tubes
Eustachian tubes The Eustachian tubes connect the nasopharynx to the middle ears; these tubes open during swallowing to equalize pressure within the middle ear. The glottis is the opening between true vocal cords. The paranasal sinuses are air-filled cavities within the bones that surround the nasal passages. Palatine tonsils are a part of the immune system and are located on the sides of the oropharynx. These tonsils protect against invading organisms.
Which mediator of injury is involved in the client with pruritic lesions from an immunoglobulin E (IgE)-mediated hypersensitivity reaction? Histamine Cytokine Neutrophil Macrophage
Histamine Histamine is one of the mediators of injury involving IgE-mediated injury and potentially causes pruritus. Cytokines are the mediators of injury in delayed hypersensitivity reaction. Neutrophils are involved in immune complex-mediated hypersensitivity reactions. Macrophages in tissues are involved in cytotoxic reactions.
Which treatment would the nurse anticipate for an infant admitted with bronchiolitis caused by respiratory syncytial virus (RSV)? Humidified cool air and adequate hydration Postural drainage and oxygen by hood Bronchodilators and cough suppressants Corticosteroids and broad-spectrum antibiotics
Humidified cool air and adequate hydration Humidified cool air and hydration are essential to facilitating improvement in the child's physical status. Postural drainage is not effective with this disorder; oxygen is used only if the infant has severe dyspnea and hypoxia. Bronchodilators are not used, because the bronchial tree is not in spasm; cough suppressants are ineffective. Corticosteroids are ineffective; antibiotics are also ineffective, because the causative agent is viral.
Which teeth would the nurse expect to erupt first in a typically developing 6-month-old infant? Incisors Canines Upper molars Lower molars
Incisors The bottom incisors are the first teeth to erupt, between 6 and 8 months of age. The canine teeth appear around 18 months. The first molars, both upper and lower, appear around 20 months.
The nurse is discussing insulin needs with an adolescent with recently diagnosed type 1 diabetes. Which information is important for the nurse to include concerning insulin administration? Insulin will be required throughout life. Insulin may be taken orally until adulthood. Insulin needs increase with strenuous exercise. Insulin needs decrease in the presence of an infection
Insulin will be required throughout life. All those involved must understand that the child does not have an endogenous source of insulin and will require insulin administration throughout life. At this time there is no oral insulin with which to treat type 1 diabetes. Insulin needs decrease, not increase, during exercise. Insulin needs increase, not decrease, in the presence of an infection.
A student athlete reports muscle pain after a practice session. Which product of muscle metabolism would the nurse explain as being a cause of pain? Lactic acid Acetoacetic acid Hydrochloric acid Beta-hydroxybutyric acid
Lactic acid The ache in muscles that have been vigorously worked without adequate oxygen supply is caused in part by the buildup of lactic acid. During rest, the lactic acid is oxidized completely to carbon dioxide and water, providing adenosine triphosphate for further muscular contraction. Beta-hydroxybutyric acid and acetoacetic acid are not products of muscle contraction; they are ketone bodies resulting from incomplete oxidation of fatty acids. Hydrochloric acid is not a product of muscle contraction; it is present in the stomach to facilitate the digestive process.
Which clinical finding suggests developmental dysplasia of the hip in an infant? Leg length discrepancy Limited ability to adduct the affected leg Narrowing of the perineum with an anal stricture Inability to palpate movement of the femoral head
Leg length discrepancy A leg length discrepancy is caused by the femoral head being displaced upward, out of the acetabulum. The child's ability to abduct, not adduct, the affected leg is limited. Narrowing of the perineum with an anal stricture does not occur with hip dysplasia. When the femoral head slips out of the acetabulum, it is palpable.
The nurse notices cyanosis in a client with heart disease. Which site would the nurse assess to confirm cyanosis? Lips Sclera Conjunctiva Mucus membrane
Lips The lips and nail beds are the best sites to assess for cyanosis. The sclera and mucous membrane are assessed in jaundice. The conjunctiva is assessed for the presence of pallor.
Which client conditions does the nurse associate with bluish-colored mucous membranes? Select all that apply. One, some, or all responses may be correct. Edema Diabetes mellitus Hemochromatosis Methemoglobinemia Cardiopulmonary disease
Methemoglobinemia, Cardiopulmonary disease A bluish color of the mucous membranes may indicate methemoglobinemia (the presence of methemoglobin in the blood, which is an oxidized form of hemoglobin) and cardiopulmonary disease in the client. The presence of a white color of the mucous membranes may indicate edema in the client. Diabetes mellitus is associated with a yellow-orange color of the palms and soles. The presence of a brown color of the distal lower extremities may indicate hemochromatosis (deposition of iron salts in the tissues).
Which is the optimal area for the nurse to assess adequate tissue oxygenation in an African-American neonate? Heels and buttocks Upper tips of the ears Nail beds on the hands and feet Mucous membranes of the mouth
Mucous membranes of the mouth Lack of skin pigmentation on the surfaces of the mucous membranes makes this the best area in which to assess this neonate's tissue oxygenation. Heels and buttocks are usually highly pigmented areas, and the buttocks often have Mongolian spots. The tips of the ears will indicate skin color later in life. Because most neonates' hands and feet exhibit acrocyanosis, the nail beds may be cyanotic as well.
A client asks the nurse what causes the sudden loss of vision common in persons with multiple sclerosis. Which factor would the nurse include in the explanation? Virus-induced iritis Intracranial pressure Closed-angle glaucoma Optic nerve inflammation
Optic nerve inflammation Optic nerve inflammation is a common early effect of multiple sclerosis caused by lesions in the optic nerves or their connections (demyelization). This effect may resolve during periods of remission. At present, there is no evidence of viral infection of the eyes in multiple sclerosis. Tumors of the brain and cerebral edema, not multiple sclerosis, cause increased intracranial pressure because the skull cannot expand. Closed-angle glaucoma causes blindness as a result of increased intraocular pressure, not inflammation of the optic nerve, which is commonly associated with multiple sclerosis. Closed-angle glaucoma is unrelated to multiple sclerosis.
Which fine motor skill should be seen in a 10-month-old infant? Picking up finger foods Releasing a cube in a cup Building towers of 2 blocks Turning many pages in a book
Picking up finger foods When an infant is 10 months old, the pincer grasp is well established, which helps the infant pick up finger foods. When an infant is 11 months, the infant should have a neat pincer grasp and be able to release a cube in a cup. One-year-old infants can build a tower of 2 blocks and turn many pages in a book.
Which gland secretes melatonin? Pineal gland Thyroid gland Adrenal gland Parathyroid gland
Pineal gland The pineal gland secretes the hormone melatonin, which regulates the circadian rhythm and reproductive system at the onset of puberty. The thyroid gland secretes thyroid hormones. The adrenal gland secretes androgens, corticosteroids, and catecholamines. The parathyroid gland secretes the hormone calcitonin.
The nurse is caring for a client with severe burns and determines that the client is at risk for hypovolemic shock. Which physiological finding supports the nurse's conclusion? Decreased rate of glomerular filtration Excessive blood loss through the burned tissues Plasma proteins moving out of the intravascular compartment Sodium retention occurring as a result of the aldosterone mechanism
Plasma proteins moving out of the intravascular compartment The shift of plasma proteins into the burned area increases the shift of fluid from the intravascular to the interstitial compartment; the result is decreased blood volume and hypovolemic shock. Decreased glomerular filtration may occur because of hypovolemia; it does not cause hypovolemia. Extracellular fluid, not blood, is lost through burned tissue. Sodium is not retained; it passes to interstitial spaces and surrounding tissue.
A primary health care provider diagnoses the client's condition as otitis media. Which assessment finding supports that diagnosis? Nodules on the pinna Redness of the eardrum Lesions in the external canal Excessive cerumen in the external canal
Redness of the eardrum Many conditions are associated with a decrease in hearing acuity. One such condition is otitis media. This condition is diagnosed by redness of the eardrum observed during the otoscopic examination. Nodules on the pinna may be an indication of rheumatoid arthritis, chronic gout, or basal or squamous cell carcinoma. Lesions in the external canal may cause a decrease in hearing acuity, but not the manifestation of otitis media. Excessive soft cerumen in the external canal affects the hearing acuity, but not the manifestation of otitis media.
Which hormone is released from the pancreas? Oxytocin Prolactin Calcitonin Somatostatin
Somatostatin Somatostatin is a hormone produced by the pancreas that inhibits the release of insulin and glucagon. Oxytocin is a hormone produced by the posterior pituitary gland that acts on the uterus and mammary glands. Prolactin is a hormone produced by the anterior pituitary gland that targets the ovaries and mammary glands in women and testes in men. Calcitonin is a hormone produced by the thyroid gland that interacts with bone tissue.
Which formula is most preferable for an infant that has lactose intolerance? Soy-based formula Whey hydrolysate formula Cow's milk-based formula Amino acid-based formula
Soy-based formula Soy-based formula is a commercially available formula that has a high amount of protein but does not contain lactose. Amino acid-based formula is preferable for a child who has food allergies. However, it is not the most preferable formula for the child with lactose intolerance. Whey hydrolysate formula and cow's milk-based formula contain high amounts of lactose.
Which organism would the nurse explain was responsible for a client's recent diagnosis of malaria? Vibrio Sporozoa Ringworm Spirochetes
Sporozoa Sporozoa such as Plasmodium malariae cause malaria. Vibrio are curved rod-shaped bacteria; these microorganisms cause cholera. Ringworm such as tinea corporis may cause mycotic infections. Spirochetes are spiral-shaped bacteria; these microorganisms may cause leprosy and syphilis.
Which method would the nurse use to best elicit the Moro reflex in a full-term newborn? Touching the infant's cheek Striking the surface of the infant's crib suddenly Allowing the infant's feet to touch the surface of the crib Striking the sole of the foot along the outer edge from the heel to the toe
Striking the surface of the infant's crib suddenly Jarring the crib produces a startle response (Moro reflex); the legs and arms extend, and the fingers fan out, while the thumb and forefinger form a C. When the cheek is touched, the head turns toward the side that was touched; this is the rooting reflex. When the feet touch the crib surface the stepping reflex is elicited; one foot is placed before the other in a simulated walk with the weight on the toes. When the bottom of the foot is stroked along the outer edge of the sole from the heel to the toe, the toes flare out. This is the Babinski reflex, which is expected because of the newborn's immature nervous system. In an adult, this reflex is a sign of neurological damage.
Which description is associated with a hematoma? The occurrence of redness in patches of variable size and shape The thickening of the skin with accentuated normal skin markings The visible swelling due to extravasation of blood of sufficient size The pinpoint, discrete deposits of blood in the extravascular tissues
The visible swelling due to extravasation of blood of sufficient size A hematoma may cause visible swelling due to the extravasation of a sufficient amount of blood. The occurrence of red patches of variable sizes and shapes indicates erythema. The thickening of the skin with accentuated normal skin markings indicates lichenifications. Petechiae are the pinpoint, discrete deposits of blood in the extravascular tissues.
Which statement describes scoliosis? The concave lumbar curvature is exaggerated. There are pathological changes in the vertebrae. There is a rotary deformity of the lateral curvature of the spine. The curvature of the thoracic spine has an increased convex angulation
There is a rotary deformity of the lateral curvature of the spine. A rotary deformity of the lateral curvature of the spine is the correct definition of scoliosis. An exaggerated concave lumbar curvature is a description of lordosis. There are no pathological changes in the vertebrae with scoliosis. A curvature of the thoracic spine with an increased convex angulation is a description of kyphosis.
Which statement is true about prescriptive theories? They are action-oriented. They explain client assessment. They focus on a specific field of nursing. They are the first level of theory development
They are action-oriented. Prescriptive theories are action-oriented. They test the validity and predictability of a nursing intervention. These theories address nursing interventions for a phenomenon, describe the conditions under which the prescription occurs, and predict the consequences. Descriptive theories help explain client assessment. A middle-range theory tends to focus on a specific field of nursing. Descriptive theories are the first level of theory development
Which adverse effect can be seen in a female client with gonadotropin deficiency and who is undergoing hormone replacement therapy? Thrombosis Hypotension Dehydration Increased thirst
Thrombosis A female client with gonadotropin deficiency is treated by replacement therapy of combined hormones, namely estrogen and progesterone. The side effect of this therapy is the increased risk of thrombosis or formation of blood clots in deep veins. Hypertension is a side effect of estrogen-progesterone therapy, not hypotension. Dehydration and increased thirst could indicate vasopressin deficiency.
Identify the type of hypersensitivity reaction associated with systemic lupus erythematosus (SLE). Type I Type II Type III Type IV
Type III SLE is an example of an immune complex-mediated, or type III, hypersensitive reaction. Anaphylaxis is an example of a type I, or immediate hypersensitive reaction. Cytotoxic, or type II, hypersensitive reactions can result in conditions such as myasthenia gravis and Goodpasture syndrome. Graft rejection and sarcoidosis are conditions caused by delayed, or type IV, hypersensitivity reactions.
Which assessment finding is consistent with bronchospasm? Wheezing Rhonchi Pleural friction rub Low-pitched crackles
Wheezing Wheezing, a high-pitched, musical, continuous sound that does not clear with coughing, is caused by airway narrowing, which occurs with bronchospasm, for example. Rhonchi are associated with obstruction by a foreign body or thick mucus. Pleural friction rub can be heard in cases of pleurisy. Pneumonia may be present in a client who exhibits low-pitched crackles.
Which fine motor skill would the nurse expect when assessing the development of an infant between 10 and 12 months of age? a. Holds a crayon b. Walks w assistance c. Stands independently d. Sits from standing position
a. Holds a crayon The ability to hold a crayon is a fine motor skill that the nurse would expect when conducting a developmental assessment for an infant between 10 to 12 months of age. Walking with assistance, standing alone, and sitting from a standing position are all gross motor skills the nurse would anticipate for this infant.
A student nurse is assessing the blood pressure of a client with the client's arm unsupported. Which is the expected error in the obtained reading? False high reading False low diastolic reading False high systolic reading False high diastolic reading
false high reading If the client's arm is unsupported, or if the arm is below the heart level, the resulting outcome is a false high reading. Application of the stethoscope too firmly against antecubital fossa will result in a false low diastolic reading. Repeated assessments of blood pressure too often result in a false high systolic reading. Deflating the cuff too slowly results in a false high diastolic reading.
